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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your CLIENT IDENTIFICATION details. Fill in the packaged date and ensure you provide your last name, first name, middle initial, gender, and date of birth.
  3. Next, complete the PATIENT IDENTIFICATION section. Include the patient's address, ordering physician's name, and treating physician's information.
  4. In the INSURANCE / BILLING INFORMATION section, select how you wish to bill (Client bill, Insurance, or Patient/Self Pay) and provide necessary insurance details including policy numbers.
  5. Fill out the CLINICAL INFORMATION section with relevant therapy details and any prior authorization numbers if applicable.
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Mar 25, 2022 CSI Laboratories P.O Box 989728 West Sacramento, CA 95798-9728 To Enroll, Please Call: 1-833-774-1232. CSI Laboratories (Enclosure) 1-800-680-

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